Late patients

Specialties Urology

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Our dialysis unit has been struggling to find a way to deal with a few of our patients who are chronically late. We run 2 shifts, so if they are late for first shift, the patient who follows them has to wait, and if they are late for second shift, the closing staff has to stay late. Sometimes these patients are half to an hour late. Our director doesn't want to cut their time, so that isn't an option (it would probably seem to be a reward to some of them!) Does anyone have any suggestions on dealing with this?

We had them sign a contract and if they continued to be late, then they were placed on the second shift. We also took them off at there scheduled time no matter when we got them on. You gave to treat pts as adults and to hold them accountable.

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I am appreciating this post since I am in the same boat, but in a worse situation. I have been an RN for an average of 2 years. 1 year at a nursing home and 2nd year at a dialysis unit. The unit has a nursing home that is part of the dialysis as well. 99% the dialysis patients come from the nursing home. I was given the opportunity to be the new dialysis administrator. I know what you may be thinking "how did she get that lucky"? I don't think I'm so lucky. It is rare, but our small unit has a 5th shift !!! We have all the problems and issues you can think of; Late patients and patients not getting their full treatment because we have to cut their treatment at the end of the night because machines need to disinfect for the next day. We would never cut a patients treatment time just because they were late, only because it is morning and the unit has to close for the a couple of hours. So Im sure the readers know I am in a very

sticky situation. I am still a newbie to the field and I am nervous. All the nephrologists want their patients to complete their prescribed time and they know I am not the one say yes to all the new admissions. The administration is aware that patients on the 5th shift aren't getting their full treatment, but they say its not that important. I asked what if the Department of Health walks in and sees whats going on ???? I get some lame response and my stomach feels like a roller coaster. My main question is what does happen to me? I feel like quitting because I don't think its ethical and I'm tired of the greed. Will I lose my RN license? Has anyone ever been in a situation like mine. Please help me.

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Specializes in Dialysis.

Is the covering nephrologist writing an order to shorten the 5th shift patient's treatments? If not, then yes you and any nurse involved could potentially lose their license. Don't think for a second that you administrator or anyone else will stick up for you when CMS gets wind that this is happening. It is our job as nurses to be an advocate for our patients. If your company is asking you to do something that can harm a patient (and yes shorting a treatment hurts the patient) then you have a responsibility to put a stop to it. I know this is a tricking situation, and it is scary to think that you can be retaliated against for speaking your mind or putting your foot down. However, it is better to walk away with you license intact and a clear conscious then to lose you license for unethical practices.

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We had them sign a contract and if they continued to be late then they were placed on the second shift. We also took them off at there scheduled time no matter when we got them on. You gave to treat pts as adults and to hold them accountable.[/quote']

Yes, you do have to hold them accountable, but not in a way that causes them harm. It is harmful to the patient to get less than their prescribed dialysis treatment. And what about our liability as nurses when we don't follow the physician's order, and take the patients off early without a medical reason? I'm pretty sure CMS wouldn't be impressed.

Thanks for everyone's replies - lots of food for thought!

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Specializes in ICU.
Yes, you do have to hold them accountable, but not in a way that causes them harm. It is harmful to the patient to get less than their prescribed dialysis treatment. And what about our liability as nurses when we don't follow the physician's order, and take the patients off early without a medical reason? I'm pretty sure CMS wouldn't be impressed.

Thanks for everyone's replies - lots of food for thought!

Showing up late was the patients choice - if they have signed behaviour contracts, they are making an informed choice that if they show up late, they will lose their dialysis time and may cause themselves harm.

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Showing up late was the patients choice - if they have signed behaviour contracts, they are making an informed choice that if they show up late, they will lose their dialysis time and may cause themselves harm.

What is the legality of this? Aren't you still not complying with the physician's order when you take the patient off early? Or are there some kind of standing orders that cover patients with behavior contracts?

I still have heartburn about behavior contracts - in essence, you are withholding a life-saving treatment based on the patient's poor behavior. I'd rather be late getting off work in the evening than choose a course of action that hurts a patient. Sometimes nursing isn't fun...

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Specializes in ICU.

I don't know about the legality in the USA, but in Australia it certainly will fly - and the nephrologists are usually aware of it as well. I don't feel like I am withholding lifesaving treatment - the patient is withholding it from themselves, AND OTHER PATIENTS if we are expected to give them full runs. If you show up late for your chemo/MRI/CT/surgical clinic/whatever appointment, you lose it. Dialysis should be no different. You need to treat the patients like adults - they make an adult decision to show up late, they have to live with the adult consequence of losing hours.

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I don't know about the legality in the USA, but in Australia it certainly will fly - and the nephrologists are usually aware of it as well. I don't feel like I am withholding lifesaving treatment - the patient is withholding it from themselves, AND OTHER PATIENTS if we are expected to give them full runs. If you show up late for your chemo/MRI/CT/surgical clinic/whatever appointment, you lose it. Dialysis should be no different. You need to treat the patients like adults - they make an adult decision to show up late, they have to live with the adult consequence of losing hours.

Yes yes yes

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Yes, this is what I have been asking for, treat dialysis patients like adults, not babies or infants. Yes, sometimes, in my area, they will be late, because I live in a big metro county and people here drive like idiots, you should see some of the accidents. The majority, if you treat them like adults, they will act like adults. If they cannot be on time, on a regular basis, they suffer because of their actions. I have left for a physician's appointment an hour early and I still had to run across the parking lot to get there on time, someone decided to drive like an idiot. I liked the staff at the Davita Dialysis Clinic that I went to, the FA was outstanding and so was the Nursing supervisor, along with the Nursing staff. I did my own needle sticking and sometimes, brought my own supplies at the request of the clinic. However, I would give patients the choice of Nocturnal if they were diabetics or had issues with fluid. Then, if they declined it, the decision is on them, not the clinic. I would give them the choice of 6-8 hour treatments, 3-4 days per week. I would show them the benefits of Nocturnal. If the government is smart, they would pay extra for the Nocturnal treatments, much cheaper than the ER for fluid overload. If they did the 8 hour treatment for 4 days per week, they probably would not have to take binders, would be my guess, if they were using a Fresenius machine, it is a workhorse. The only thing I do not like about that machine is all of the alarms. The U.S. medical system is goofy......... Paying for the ER instead of a primary physician and some medicine....... Use the primary physician and some medicine, huge cost savings or a NP, along with a physician's assistant with some medicine, more cost savings. In many cases, physicians are not needed for basic medicine..... The NP's or Physician's Assistants that I have used have been outstanding....... along with Nurses have been great. When I have an issue, first person I call is a Nurse, my RN sister or if it is a dialysis issue, Dialysis RN...... Physicians are truly needed for the hard and complex cases, such as a staph infection, acute pneumonia, or a fistula infection.

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Specializes in Nephrology, Cardiology, ER, ICU.

Lets get back on topic please: what to do with late patients:

1. Ensure that your company's p/p manual back you on this but have the pt sign an agreement to a specific tiime - this will need to be done for ALL pts.

2. If pts are late, their time is cut, no exceptions. (Again in keeping with your company's policy).

3. Involve the nephrologist, NP/PA to ensure adequate documentation and counseling occurs.

4. Offer to move them to a different shift if possible, maybe a switch could be arranged.

5. Offer other modalities of dialysis: home hemo, PD

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